Asthma Annual Review Questionnaire

2.
In the last month, have you had any difficulty sleeping because of your
asthma symptoms (including cough)?

Details of sleeping difficulties:

3.
In the last month, have you had your usual asthma symptoms during the
day? (cough, wheeze, chest tightness or breathlessness)?

Details of symptoms during the day:

4.
How often do you use your blue inhaler?

Details of inhaler use:

5.
In the last month has your asthma interfered with your usual activities
(e.g. housework, work, school etc)?

No

Yes

6.
Have you ever had your peak flow measured at the surgery?

No

Yes

If yes, do you know your best PEFR value

ml/min

7.
Are you happy with your inhaler technique?

No

Yes

If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.

8.
Have you ever smoked?

No

Yes

If 'Yes', please answer the following:

Do you smoke now?

No

Yes

If 'Yes' how many do you smoke each day?

If 'No' when did you quit?

There are plenty of options available to help you quit. Is this something you would
like us to contact you about?

No

Yes

About This Form

You are due an annual asthma review. Please answer the questions
and submit this form to us. If your symptoms are deteriorating or you have any concerns,
please make an appointment to the respiratory nurse or a Doctor as well.

Fields marked with a red asterisk arecompulsory.

Note:
By using this form you will be sending information about yourself across the Internet.
Whilst every effort is made to keep this information secure, you should be aware
that we cannot offer any guarantees of absolute privacy. If this matter concerns
you then you should use another method to notify us of your information.

Personal Information

Personal information retained on this system is stored in a secure data centre located
in the UK and is treated as confidential.